This policy statement calls for the development and implementation of public health systems for identifying, assisting, and intervening to protect children at risk of or with harmful environmental exposures at school. Such systems would add protections for the 55 million children enrolled in prekindergarten to grade 12 (PK–12) public and private schools who are at risk for or who have suspected environmental exposures in those settings. Despite decades of advocacy for environmentally safe and healthy schools that protect children’s health, the physical environment of too many schools remains poor. The poorest, highest-risk learners often attend schools in the worst condition, placing them at increased risk for adverse health outcomes as well as diminished learning. This policy calls for establishing systems to identify and protect children at risk of harmful environmental exposures in schools and adds more support for APHA’s calls to rebuild the nation’s public school infrastructure. The policy’s primary purpose is to address the public health needs of children at risk. It also recognizes the government’s responsibility to monitor the physical environment of PK–12 public schools and ensure that children are protected from exposures to harmful environmental conditions. The necessary systems would include tracking of the environmental quality of school buildings, national standards for facilities, training for those responsible for facilities, research to guide standard setting, and the resources to carry out recommendations, such as facility remediation funds. In addition, the statement calls for enhanced coordination across all governmental agencies, delineating clear lines of authority and responsibility.

Children’s unique biological and behavioral vulnerabilities to environmental hazards include breathing more air per pound of body weight than adults, consuming more food and water per pound than adults; having more permeable skin, having developing organ systems, lacking the ability to recognize and understand hazards, lacking the authority or ability to leave harmful environments, and not having the knowledge or language to articulate exposures.[1–4] Furthermore, children have more time than adults to develop chronic diseases that toxic chemicals trigger, such as cancer and neurodegenerative diseases.[5] In 2008, the estimated cost of childhood diseases associated with chemical substances in the environment was $76.6 billion.[6] How many of those costs are attributable to exposures at school is unknown since no entity at the national or federal level (and often none at the city or state level) routinely monitors environmental hazards in such locations or the exposures of the children in them.

Conditions of schools: All states have compulsory education laws; today some 55 million children attend about 130,000 public and private kindergarten through 12th-grade schools (and some with onsite prekindergartens, collectively referred to hereafter as “PK–12” or “schools”).[7,8] By the time people graduate from high school, they have spent on average 15,600 hours inside a school building.[9] In 2011, the U.S. Environmental Protection Agency (EPA)[10] estimated that more than 45% of public schools in the United States had environmental conditions that contributed to poor indoor air quality. Other studies of America’s schools have shown that many are in substandard condition, with poor ventilation, sanitation, lighting, acoustics, chemical management, and/or pest and pesticide controls. Many classrooms have poor ventilation, which can erode critical thinking skills[11]; fixing indoor air quality by increasing ventilation rates and lowering carbon dioxide levels has been shown to have a positive impact on cognitive functioning.[12] Unfortunately, the physical conditions of schools are worsening rather than improving as a result of years of deferred maintenance and inadequate investments.[13–15] In 2017, the American Society of Civil Engineers assigned the U.S. school infrastructure a grade of D+.[15] The midcourse review of Healthy People 2020[16] reported the following:

The percentage of elementary, middle, and high schools that had an indoor air quality management plan decreased from 51% in 2006 to 46% in 2014, moving below the baseline and well below the 2020 target.

The percentage of elementary, middle, and high schools that informed students and staff prior to the application of pesticides decreased from 65% in 2006 to 35% in 2014, again below the baseline and well below the 2020 target.

Between 2006 and 2014, the percentage of elementary, middle, and high schools that inspected drinking water outlets decreased from 56% to 46% for lead and from 55% to 48% for coliforms, moving below their respective baselines and away from their 2020 targets.

Although no surveillance systems track school environmental hazards or children’s exposures in schools, documented cases of environmental hazards severe enough to force school closures probably represent the tip of the iceberg. Recent examples of forced school closures include[9]:

elevated carbon monoxide levels in a Dallas elementary school discovered when a dozen children became ill and others reported headaches

elevated levels of trichloroethylene and tetrachloroethylene in a Massachusetts elementary school that caused eye irritation, respiratory symptoms, dizziness, and headaches

mold in multiple areas that closed an entire California school district

abnormal levels of volatile organic compounds in a K–12 Wyoming school that caused headaches, rashes, and hives and led to a kitchen staff employee being medevaced to a hospital

high radon levels in an Oregon K–8 school that placed occupants at risk for lung cancer

In addition to the threats to health just cited, other exposures can affect health and school performance. A study of New York schools showed that visible mold, humidity, and poor ventilation were each independently associated with higher rates of absenteeism.[17] Lead exposure in young children affects cognitive development, yet testing of drinking water in schools revealed elevated lead levels in 30 Atlanta schools, 26 Chicago schools,[9] and 14% of taps tested in all New York State public schools outside of New York City.[18] The drinking water in most schools nationwide has not been tested.

An equity issue: The poor conditions cited above reflect health equity issues. The poorest children often attend the facilities in the poorest condition and might be even more vulnerable than their peers.[13,19,20] The condition of school buildings is a long-standing civil rights issue[21] and was the initial impetus for Brown v. Board of Education. Even though integration officially occurs, low-income children are still concentrated in schools in poor condition or in portable classrooms that can have an array of air pollutants from interior materials and furnishings.[22] In addition, many schools are located on compromised sites: one study revealed that schools in areas with the highest air pollution levels had the lowest attendance rates and test scores.[23] Two studies from New York State showed that as the percentage of students who qualify for free and reduced-price lunches increases (a measure of income), the quality of a school decreases, with non-White and poorer students being disproportionately affected.[9] A study of 1900 schools in Massachusetts[9] revealed a relationship between chronic absenteeism and outdoor air quality and surrounding green space. One of the best predictors of school success is attendance, and school success reduces gaps in health and life expectancy associated with socioeconomic status.[24] The Community Preventive Services Task Force has identified education as the social determinant of health with the best evidence of effective interventions that lead to improved health status.[25]

The passage of the Individuals with Disabilities in Education Act (IDEA) has led to the enrollment of even more children with disabilities and chronic health conditions in public schools.[26] Under the IDEA, schools have an obligation to provide an education for those with disabilities in the least restrictive environment possible and thus should address the environmental factors contributing to disabilities or impeding thinking and learning. However, children with disabilities may experience worse classroom environmental conditions than their peers while being even more vulnerable to such conditions.[19]

Asthma is recognized as a disability and has clear environmental contributors. Reducing asthma triggers is an important aspect of making an educational environment suitable for children with asthma. Instead, asthma is a leading cause of school absenteeism due to illness and resulted in 13.8 million missed schools days in 2013.[27] Pediatric asthma hospitalizations can triple after children’s return to school after weekends and holidays.[28] In addition, work-related asthma has been found in the educational services industry.[29]

Lack of governmental authority or responsibility: No federal agency has responsibility for improving school physical environmental conditions or for preventing, identifying, or managing children’s environmental health in schools. The U.S. Department of Education influences what happens in state and local education agencies through funding but provides no grants or guidance for schools’ physical environments; its long-standing budget line to support a federal education facilities clearinghouse was eliminated in the Every Student Succeeds Act (2015), but its National Center for Education Statistics counts facilities and has intermittently surveyed school leaders on facility needs. The U.S. Department of Health and Human Services has only a few school-directed initiatives and none at the National Center for Environmental Health or the Agency for Toxic Substances and Disease Registry (ATSDR). The Centers for Disease Control and Prevention (CDC) provides limited funding to state health and state education agencies for school health programs, but none of these programs address the physical environment. CDC’s Division of Adolescent and School Health included a few physical environment questions in its School Health Policies and Programs Study (the source of the Healthy People 2020 data). That survey has been discontinued, however, so the data will no longer be available.[30] No regularly administered national survey or data sources include information about the environmental conditions of school buildings.[15]

The EPA has several regulatory programs affecting schools (programs addressing lead in paint, asbestos, polychlorinated biphenyls, drinking water, and hazardous waste), and for more than 20 years the agency has provided federal leadership by advancing guidelines on preventing common environmental problems in schools through national and regional grants, research, and annual symposia, largely from its Indoor Environments Division. EPA’s Office of Children’s Health Protection has provided guidelines and grants to address school siting and to develop state interagency plans for improving school environments; the office also co-funds, with ATSDR, the Pediatric Environmental Health Specialty Units network, which offers physician training and community consultations and information on pediatric environmental health.

EPA’s voluntary programs and grant funds for addressing school environments and child health have been deeply diminished, however.[31] The only authority that the Occupational Health and Safety Administration (OSHA) has over schools is as workplaces for the adults working in them; they do not have any authority with respect to children, who are both more numerous in schools and more vulnerable to toxic exposures than most adults. Also, OSHA has limited authority over schools because most school personnel are public employees and are thus exempt from federal OSHA initiatives unless their state has adopted a state OSHA plan. Similarly, the National Institute for Occupational Safety and Health (NIOSH) cannot evaluate suspected exposures of children because the agency is limited to research and evaluation on the impact of workplace factors on adult workers. Two NIOSH studies illustrate the need for systems that address exposures among schoolchildren. First, a rare NIOSH health hazard evaluation that engaged a state health agency revealed that proportionally more schoolchildren than school personnel were reported with eye, cough, and headache problems.[32] Second, in a NIOSH study assessing school personnel (although an independent, contemporaneous survey), parents reported that their children had new health problems after returning to contaminated schools damaged by the collapse of the World Trade Center towers on September 11, 2001.[33] Major tragedies often alert the public to the importance of public health and the need for surveillance[34]; the lack of services for children required to attend contaminated schools after 9/11 or attending schools forced to close due to environmental hazards should be no exception.

States have the primary responsibility for public education, but many states delegate that authority to local school jurisdictions. A number of states and localities lack, or do not define, authority for preventing, identifying, or managing environmental health threats to children in schools, or they may ignore them.[7,35–37] Even when schools have damage or contamination from natural or man-made disasters, no agencies routinely address environmental risks specific to children as the primary occupants of damaged facilities.[7,33]. In addition, the U.S. Departments of Health and Human Services, Labor, and Education and the EPA, as well as states, lack data on children’s environmental health and safety at school.[7–9,15,38,39]

Given that all states require children to attend school; given the compelling and growing evidence of how poor school environmental conditions adversely affect children’s health, thinking, and learning; and given decades of poor environmental conditions in too many schools, it is a moral imperative to create systems that ensure identification and appropriate interventions to prevent (further) harm to children at risk or with suspected environmental exposures in these settings. Establishing environmental public health systems for protecting and caring for children while they are at school is an essential government obligation and is vital to improving children’s health, educational outcomes, and well-being.

Evidence-Based Strategies to Address the Problem

Previous APHA policies have called for improving school facilities (i.e., primary prevention). This statement builds on previous APHA policy statements and calls on the nation’s public health agencies to establish systems for assisting children at risk or with suspected environmental exposures in public and private schools. Such systems would include complaint tracking and investigation, training on recognizing and remediating hazards, and standards based on health hazard studies, research reports, and benchmarking of preventive efforts that address hazards in schools. The systems would require cross-sector coordination and collaboration as well as resources.

Surveillance systems for risks and suspected exposures that affect children’s health and performance: According to the CDC, surveillance is the foundation of public health practice.[40] In order to determine the extent of a problem and to monitor progress, surveillance systems must be in place. A surveillance system for environmental risks and children’s exposures in schools does not exist in the United States. A robust system would include regularly scheduled data collection, mechanisms for reporting suspected or actual exposures in real time, and a central repository for compiling information. A start to establishing such systems could be collecting and analyzing complaints and establishing a repository or repositories for the collected data, as recommended in the 2015–2016 Environmental Health at School report and recent reports from the Healthy Schools Network.[7,8,35] To improve school facilities, there is also a need for reliable information about the condition of the nation’s schools. A 2017 Harvard study on how school buildings affect children recommended a national school infrastructure assessment.[9]

Training and resources related to identifying and remediating environmental risks and exposures at schools: Few public health professionals or health care professionals, let alone educators, school support staff (e.g., custodians), or parents, have the training or expertise needed to recognize or correct environmental hazards found in schools. Many harmful effects of exposures go unrecognized and unaddressed. Without knowledge of environmental risks to children’s well-being and academic success or of ways to remediate or prevent such risks, even the most well-meaning and resourced education or facilities professional will probably fail to provide optimum protection for all children. The EPA has developed training materials on improving school environments that could serve as the foundation for expanded training of education leaders and staff.

Because they are often the first providers to see children with complaints that could indicate exposure to environmental hazards, health care providers, especially school nurses, others providing school health care, and pediatricians, need to be able to make the connection between symptoms and exposures. Many lack training on recognizing and responding to suspected or actual school-based environmental hazard exposures, especially before the exposures place a child’s health or academic performance at risk. Basic training should build on the nationwide efforts of the Pediatric Environmental Health Specialty Units network and should include (1) identification of potential environmental hazards in schools, (2) recognition of symptoms that might indicate an environmental cause, and (3) communication of concerns with the school, parents, and appropriate public health and/or environmental protection agencies.

Available resources include those designed by the award-winning Healthy Schools/Healthy Kids ClearinghouseSM (operated by the Healthy Schools Network) for parents and personnel, which focus on recognizing, addressing, and preventing environmental health risks and exposures in schools. The EPA’s multiple documents on school environments also offer guidance.

In some instances, needed resources would include funding, such as when poor construction or deferred maintenance results in major costs to ensure an environmentally safe place for children. In other instances, needed resources might involve little if any out-of-pocket costs; examples include knowledge of what to look for, how to report, authority to act, and even green cleaning supplies. Needed resources would also include access to trained school nurses and other school health care providers, in addition to qualified environmental health professionals who could conduct on-site school investigations of suspected or reported environmental hazards. Until the extent of the problem is known, it is difficult to predict the expected benefits or costs.

Guidelines and standards: The evidence is clear that improved school environments reduce absenteeism, improve academic performance and attentiveness, and reduce the incidence of communicable respiratory diseases and asthma episodes.[41,42] School environmental conditions that affect the health and success of children include (but are not limited to) indoor air quality, drinking water, air temperature, lighting, noise levels, moisture, dust, and animal dander and feces.[9] Having standards focused on reducing hazards would help those who are responsible for ensuring that schools support children’s health and learning.

In the case of many environmental conditions, acceptable levels are determined from studies of adult exposures. Having a central repository for documentation of known exposures in schools; for research about the relationship between school environmental conditions and the performance and health of children, faculty, and staff; and for routine surveillance data would provide a sound basis for developing and updating standards related to healthy school environments. With the information now available, the EPA has developed Healthy Schools/Healthy Children Web pages for guidance and regulations; there is no process for updating this guidance as new information becomes available, however, and many schools are unaware that this resource exists.

Having benchmarks informed by evidence would, in turn, inform robust data collection systems that focus on known risks to children’s health and academic success. The 2017 Harvard study’s recommendations included creating a national set of standardized health performance indicators that could be modeled on the Massachusetts school metrics and research tool (MA SMART).[9]

Although a number of states have laws on key environmental topics such as indoor air, integrated pest management, green cleaning, and school design, the laws vary widely from state to state.[8] Few state agencies and even fewer local schools have the needed expertise to create environmental standards for schools based on the latest research. Even if they did have such expertise, asking states to duplicate efforts by developing standards independently is wasteful. With national guidance, states could accelerate policy improvements.

Authority and accountability for children and for the quality of schools: When no one collects data, no entity has clear authority to act, and no one is held accountable, the likelihood of action is minimal. Because the authority for both public health and education in the United States rests in the states, and because states often delegate authority to local entities and accept guidance and funding from the federal government, this policy statement calls for convening governmental agencies at the federal, national, state, and local levels to clarify lines of authority and ensure that needed policies and services are provided in a seamless way.[43] Ensuring that children’s civil rights and disability rights are protected at school requires coordination not only with the U.S. Department of Education but also with the Justice Department, the EPA, and the Department of Health and Human Services. It also might benefit from coordination between schools and communities, as in the Whole School/Whole Community/Whole Child model.[44] Once lines of authority are clarified, making certain that schools understand expectations requires that the public health system, the education system, and the families of children attending know who is accountable and how to ensure both children’s health and a healthful school facility. Establishing public health systems for children in schools will require new capacity and resources to support coordination efforts. On the facility side, the Harvard study calls for the creation of a national director of school infrastructure who could provide coordination at the federal level for improving these settings.[9]

Opposing Arguments/Evidence

One argument against remediating hazards is that the cost would be prohibitive. However, if schools perform regular maintenance and repair facility problems promptly, they can save money in the long run, even avoiding costly remediation and major renovations.[45] One study estimated that for every dollar of deferred maintenance, the eventual cost is $4 of repairs.[46] Furthermore, as a society, we pay the direct cost of increased health care for children who have exposures, many of whom are on Medicaid or Children’s Health Insurance, as well as for the loss of their potential as a result of chronic health conditions or diminished educational attainment. More immediately, local schools can lose state attendance revenues when children are not present due to illnesses. Society also suffers when school environmental problems lead to lower test scores, less “seat time,” or increased absenteeism, compromising children’s educational outcomes.[11]

Another argument is that increased regulation of schools is counter to the political move toward deregulation and that increased regulatory oversight costs taxpayers’ money. Because every state requires children to attend school, the government has a responsibility to protect children’s health and ability to learn while they are at school. Young children do not have the knowledge to recognize hazards or leave schools on their own, nor do they have the political power to advocate for change, yet considerable research documents that children’s learning is enhanced and that they are healthier if their physical environment is healthier.[11] An appropriate role of government is to protect the most vulnerable, including young children (especially those who may be medically fragile), and to ensure that environmental factors adversely affecting children’s health and learning at school are reduced or eliminated.

Authorizations and jurisdictional issues among various governmental entities can lead to inaction. Local school boards govern public schools at the local level; however, schools are also subject to city, state, and federal education, health, environment, and labor laws. States have authority over their PK–12 systems and public health but often delegate to local authorities.[47] Although federal agencies and national organizations may develop standards and guidance and provide funding, they do not have regulatory authority (other than for the EPA). State education agencies, some of which accredit schools, visit schools infrequently, if at all, and assess educational factors as opposed to environmental ones. Few if any state education agencies have the mandate or expertise to ensure healthy school environments or to enforce federal and state laws. The EPA has such expertise but no authority and steeply reduced resources for research, training, or demonstration grants to improve PK–12 schools.

The action steps below link to the strategies and are consistent with the recommendations of two national conferences that engaged 76 senior staff from 46 agencies and nongovernmental organizations convened by the Healthy Schools Network.[35,48] They called for establishing systems that address the environmental risks to children who spend a large amount of time in school environments, many of which present hazards known to affect their health, thinking, and learning.

Action Steps

Therefore, APHA calls on:

State health or environmental agencies tocreate reporting and investigating mechanisms. They could receive complaints of environmental risks and exposures at schools and conduct or commission investigations that would identify causes and remedies as well as explore patterns indicating broader environmental health risks. They could contract or collaborate with the federally designated Pediatric Environmental Health Specialty Units network. State agencies could also establish informational support services for schools and parents of affected children so that they could remedy environmental problems.

A federal agency such as the EPA or the CDC to create a model and implement a tracking system for child exposures. In coordination with other federal agencies (e.g., EPA, CDC, ATSDR, Department of Education), as well as with the Council of State and Territorial Epidemiologists, one federal agency would take the lead in establishing and maintaining a surveillance system for tracking children’s exposures to environmental hazards in schools. The system would include the complaints received by state and local agencies along with information from hospital emergency departments, Medicaid claims, and other sources that might become available through electronic medical records. The system data fields would include unique school building identifiers, symptoms, contributing environmental factors, and precipitating causes of exposures.

Researchers and research funders to examine the relationships between school facility factors and children’s health and academic performance, the impact on children of environmental hazards known to affect adult health and performance, and children’s health in educational facilities where NIOSH is conducting an adult worker health hazard evaluation or a related study.

Environmental health specialists to work with education leaders, teachers’ unions, college and university faculty, public health practitioners, health care providers (including pediatricians and school nurses), and parents to develop training, education, information and referral, and guidance programs focused on recognizing environmental hazards in schools, identifying students at risk or exposed, remediating hazards, and reporting issues. The programs should be geared to school faculty, staff, and administrators; education policymakers; health care providers; and public health professionals. In addition, they should provide information for families of exposed children on what to watch for and how to advocate for their children.

The EPA and the CDC, advised by the Department of Education and national organizations such as the American Academy of Pediatrics or APHA, to convene a standards-setting body that would review current guidance and available research about school environments, children’s environmental health, and occupants’ health and performance, as well as policies and practices that prevent risks to school occupants. Reviews would include policies already adopted by some states along with federal documents such as the EPA’s Healthy Schools/Healthy Children guidance materials and information from national organizations concerned about children’s health. Standards to prevent or reduce risks could also take into account the context of schools as part of communities (e.g., the Whole School/Whole Community/Whole Child model).

State agencies to adopt standardsconsistent with those agreed upon by the standards-setting body and then implement policies and processes for ensuring compliance. Policies might include state laws and regulations as well as local school board policies and school rules. Processes might include routine inspections, reports to the public, and assistance in locating and securing contractors and suppliers familiar with the standards. Standards and processes must apply to new facilities; renovations, retrofitting, or remediation of existing facilities; and routine maintenance. The processes would also include mechanisms for informing local education agencies about the standards and providing training.

Legislators, courts, and regulatory agencies and authorities to strengthen federal civil rights and disability protections by specifically including equal access to educational facilities free of environmental factors that diminish children’s health or ability to learn. Regulatory authorities would develop mechanisms that schools or health care providers could use to identify children at higher risk of harm than their peers due to environmental factors and to incorporate environmental protections they need in individualized education plans (IEPs) or 504 plans (for students with health conditions or disabilities).

Federal, state, local, and tribal agencies, as well as private foundations and businesses, to provide resources for the development and implementation of new surveillance and monitoring systems, training for those on the front lines (including families of affected children), convening standards-setting meetings, and collaborative activities among federal and state environment, public health, and education agencies for implementation of these recommendations. Additional funding would ensure the availability of professionals with the necessary expertise to provide support for the pediatric environmental health units currently partially funded by the EPA and for the staff and resources of the agencies charged with implementation. Any major federal or state funding for building or renovating public schools should prioritize those schools whose environments place children at risk and should require that plans provide for environmentally healthy school facilities.

Education, public health, and environmental protection agencies at the federal and state levels to develop mechanisms thatensure cross-agency collaborationfor protecting children’senvironmental health at school. Collaboration must occur both across agencies at the same governmental level and across levels in order to coordinate efforts, increase the level of understanding regarding what works, and promulgate standards.

4. Federal Executive Order 13045: Protection of Children from Environmental Health and Safety Risks. Available at: https://www.gpo.gov/fdsys/pkg/FR-1997-04-23/pdf/97-10695.pdf. Accessed January 4, 2018.

18. New York State Department of Health. Lead in school drinking water status: report to the governor, temporary president of the Senate, and speaker of the Assembly. Available at: https://www.health.ny.gov/press/releases/2017/docs/lead_in_school_drinking_water_report.pdf. Accessed January 4, 2018.

26. National Association of School Nurses. The case for school nursing. Available at: https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Advocacy/advocacy_The_Case_for_School_Nursing.pdf. Accessed January 4, 2018.

27. Centers for Disease Control and Prevention. Asthma-related missed school days among children aged 5–17 years. Available at: https://www.cdc.gov/asthma/asthma_stats/aststatchild_missed_school_days.pdf. Accessed January 4, 2018.

29. Centers for Disease Control and Prevention. Work-related lung disease: estimated prevalence by industry and sex, U.S. working adults aged ≥18 years, NHIS 2004–2011. Available at: https://wwwn.cdc.gov/eworld/Data/Current_asthma_Estimated_prevalence_by_industry_and_sex_US_working_adults_aged_18_years_NHIS_20042011/866. Accessed January 4, 2018.

34. Marmagas SW, King LR, Chuk MG. Public health’s response to a changed world: September 11, biological terrorism, and the development of an environmental health tracking network. Am J Public Health. 2003;93:1226–1230.

36. Loukmas H, Boese S, McCoy M. Unwanted Exposure: Preventing Environmental Threats to the Health of New York State’s Children: A Report of the Children’s Environmental Health Partnership of New York State. Albany, NY: Learning Disabilities Association of New York State and Healthy Schools Network; 2007.

37. National Association of School Nurses and Healthy Schools Network. New data show schools ignore children’s health: groups urge action by EPA and states. Available at: http://www.healthyschools.org/NASN-HSN_survey-press_Jan_2011.pdf. Accessed January 4, 2018.

42. Neilson CA, Zimmerman SD. The effect of school construction on test scores, school enrollment, and home prices. J Public Econ. 2014;120:18–31.

43. Public Health Law Center. State and local public health: an overview of regulatory authority. Available at: http://publichealthlawcenter.org/sites/default/files/resources/phlc-fs-state-local-reg-authority-publichealth-2015_0.pdf. Accessed January 4, 2018.